Pressure ulcer (pressure sore)

Pressure ulcer (pressure sore)

Definition:

A pressure ulcer is an area of skin and tissue that becomes injured or broken down. Generally, pressure ulcers occur when a person is in a sitting or lying position for too long without shifting his or her weight. The constant pressure against the skin causes a decreased blood supply to that area. Without a blood supply, the area cannot survive and the affected tissue dies.

The most common places for pressure ulcers are over bony prominences (bones close to the skin), such as the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

Alternative Names:

Bedsore; Decubitus ulcer

Considerations:

While it is more common for people to get pressure ulcers if they spend most of their time in bed or use a wheelchair, people who can walk can also get pressure ulcers when they are bedridden as a result of an acute illness or injury.

Causes:

Factors which increase risk for pressure ulcers include:

Age -- elderly people are at higher risk
Inability to move certain parts of the body without assistance, such as with spinal or brain injury patients, and patients with neuromuscular diseases
Malnourishment
Being bedridden or in a wheelchair
Having a chronic condition, such as diabetes or artery disease, that prevents areas of the body from receiving proper blood flow and nutrition
Urinary incontinence or bowel incontinence (moisture next to the skin for long periods of time can cause skin irritation that may lead to skin breakdown)
Fragile skin
Mental disability from conditions, such as Alzheimer's (some patients may not be capable of taking the proper steps toward prevention and may not seek appropriate treatment when an ulcer has formed)

Symptoms:

The National Pressure Ulcer Advisory Panel (NPUAP) created a process for evaluating pressure sores based on a staging system from Stage I (earliest signs) to Stage IV (worst):

Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.
Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.
Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

First Aid:

Once a pressure ulcer is identified, certain basic steps must be taken immediately. These include:

Relieving the pressure to that area. Use pillows, special foam cushions, and sheepskin to help reduce the pressure.
Treating the sore. Treatment will be based on the stage of the ulcer. Your health care provider will give you specific treatment and care instructions.
Avoiding further trauma or friction. Powdering the sheets lightly can help decrease friction in bed. (There are many items made specifically for this purpose -- check a medical supplies store.)
Focusing on improving nutrition and other underlying problems that may affect the healing process.
If the pressure ulcer is at Stage II or worse, your health care provider will give you specific instructions on how to clean and care for open ulcers, as it is very important to do this properly to prevent infection.
Keep the area clean and free of dead tissue. Your health care provider will give you specific care directions. Generally, pressure ulcers are rinsed with a salt-water rinse that removes the loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers.

Do Not:

Do NOT massage the area of the ulcer because massage can cause tissue damage under the skin.
Donut-shaped or ring-shaped cushions are NOT recommended because they can interfere with the blood flow to that area and cause complications.

Call immediately for emergency medical assistance if:

The patient's health care provider should be contacted immediately if there are any signs that the pressure ulcer is getting infected. An infection can lead to serious problems because the infection can spread to the rest of the body. Some of the signs of an infected pressure ulcer include:

A foul odor from the ulcer
Redness and tenderness around the area of the ulcer
The skin close to the ulcer is warm and swollen

If the patient starts running a fever or have other symptoms, such as weakness or confusion, he or she may be developing a systemic infection that can be very serious.

Prevention:

Education of at-risk patients and their families is the most productive way to prevent pressure ulcers. Steps toward prevention include:

Identifying individuals at high risk for pressure ulcers.
Ensuring that immobile patients change their position at least every two hours to relieve pressure.
Using items that can help reduce pressure caused by bedsheets and wheelchairs (e.g., pillows, sheepskin, foam padding, and powder to relieve pressure).
Making sure patients eat healthy, well-balanced meals.
Encouraging daily exercise, including range-of-motion exercises for immobile patients.
Following good skin care, including inspecting the skin every day and keeping skin clean and dry. Incontinent people need to take extra steps to limit areas of moisture.

Review Date: 7/11/2002
Reviewed By: Michael Lehrer, M.D., Department of Dermatology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.

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